Provider Demographics
NPI:1073681227
Name:ULRICH, COREY DIETRICH (PT, MSPT)
Entity Type:Individual
Prefix:MS
First Name:COREY
Middle Name:DIETRICH
Last Name:ULRICH
Suffix:
Gender:F
Credentials:PT, MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:966 N GARDEN RIDGE BLVD
Mailing Address - Street 2:SUITE 530
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-2876
Mailing Address - Country:US
Mailing Address - Phone:972-420-6605
Mailing Address - Fax:972-436-2770
Practice Address - Street 1:400 W ARBROOK BLVD
Practice Address - Street 2:SUITE 151
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-3181
Practice Address - Country:US
Practice Address - Phone:817-472-8383
Practice Address - Fax:817-472-8386
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1125342225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81646TOtherBCBS ID
TX1125342OtherPHYSICAL THERAPIST - REGULAR LICENSE
TX2844359-01Medicaid
TX2844359-01Medicaid
TXTXB152627Medicare PIN
TXTXB163934Medicare PIN